ABOUT 'BEAT YOUR A-FIB'...


"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su Cavanaugh Heart Center, Phoenix, AZ

"Your book [Beat Your A-Fib] is the quintessential most important guide not only for the individual experiencing atrial fibrillation and his family, but also for primary physicians, and cardiologists."

Jane-Alexandra Krehbiel, nurse, blogger and author "Rational Preparedness: A Primer to Preparedness"



ABOUT A-FIB.COM...


"Steve Ryan's summaries of the Boston A-Fib Symposium are terrific. Steve has the ability to synthesize and communicate accurately in clear and simple terms the essence of complex subjects. This is an exceptional skill and a great service to patients with atrial fibrillation."

Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School

"I love your [A-fib.com] website, Patti and Steve! An excellent resource for anybody seeking credible science on atrial fibrillation plus compelling real-life stories from others living with A-Fib. Congratulations…"

Carolyn Thomas, blogger and heart attack survivor; MyHeartSisters.org

"Steve, your website was so helpful. Thank you! After two ablations I am now A-fib free. You are a great help to a lot of people, keep up the good work."

Terry Traver, former A-Fib patient

"If you want to do some research on AF go to A-Fib.com by Steve Ryan, this site was a big help to me, and helped me be free of AF."

Roy Salmon Patient, A-Fib Free; pacemakerclub.com, Sept. 2013


Catheter Ablation

New FAQ: Does Ablation Reduce Heart’s Pumping Volume?

Our new Frequently Asked Questions & Answers (FAQs) is about the heart’s blood pumping capacity after an ablation.

“I’m a life-long runner. I recently got intermittent A-Fib. Does ablation (whether RF or Cryo) affect the heart’s blood pumping output potential because of the destruction of cardiac tissue? And if so, how much? One doc said it does.”

As a fellow runner, I understand your concern on how an ablation might affect your ability to resume your athletic activities.

Lesions at PVs openings

Seek Your Cure: Keep in mind, with Atrial Fibrillation you lose 15% to 30% of your heart’s normal pumping volume along with lower oxygen levels. Your body and brain aren’t getting the blood and nourishment they need. An catheter ablation is an important way to improve or restore your heart’s pumping volume.

PVAI - Ccommon lesion set at A-Fib.com

More extensive lesions pattern

Ablate as Little Tissue as Possible: A common ablation technique for paroxysmal A-Fib (using RF or Cryo), ablates only around the opening of each Pulmonary Vein (PV) and isn’t likely to affect the heart’s output.

On the other hand, more extensive lesion patterns affecting more tissue may affect the heart’s output. For example, during a PV Wide Area Antrum Ablation, instead of just ablating around each of the PV openings, large, oval lesions are made in the left atrium encircling both the upper and lower vein openings.

My Best Advice to Runners with Atrial Fibrillation

For a runner, a more extensive ablation of the left atrium may affect heart output more than circular lesions of each vein opening. …Continue reading my answer…

In A-Fib for 15 Years, Eventually Unable to Work

Terry Traver' s story at A-Fib.com

Terry Traver’ s story

We’ve posted a new personal experience story. Terry Traver of Thousand Oaks, CA, shares his 15-year battle with A-Fib.

“For over 15 years I suffered with A-Fib. It was not so bad [at first]. I stopped using caffeine and chocolate and cut back on my [alcohol] drinking.

Every three months or so I would have an episode that would last about 15 hours and then I would be fine. Meds never really helped in my case.

A-Fib Progresses to Severe and Incapacitates

In 2011, my A-Fib became severe to the point where I was almost completely incapacitated [Persistent Atrial Fibrillation]. I was not even able to work. …Continue reading Terry’s story…

Top 10 List #1 Find the best EP your can afford - A-Fib.com

FAQs A-Fib Ablations: A Runner’s Heart After Ablation

 FAQs A-Fib Ablations: A Runner’s Heart 

Catheter ablation illustration at A-Fib.com

Catheter ablation

27. “I’m a life-long runner. I recently got intermittent A-Fib. Does ablation (whether RF or Cryo) affect the heart’s blood pumping output potential because of the destruction of cardiac tissue? And if so, how much? One doc said it does.”

As a fellow runner, I understand your concern on how an ablation might affect your ability to resume your athletic activities.

Seek Your Cure: Keep in mind, with Atrial Fibrillation you lose 15% to 30% of your heart’s normal pumping volume along with lower oxygen levels. Your body and brain aren’t getting the blood and nourishment they need. An catheter ablation is an important way to improve or restore your heart’s pumping volume.

Catheter Ablation Lesions around PV openings at A-Fib.com

Lesions around PV openings

Ablate as Little Tissue as Possible: A common ablation technique for paroxysmal A-Fib (using RF or Cryo), ablates only around the opening of each Pulmonary Vein (PV) and isn’t likely to affect the heart’s output.

On the other hand, more extensive lesion patterns affecting more tissue may affect the heart’s output. For example, during a PV Wide Area Antrum Ablation, instead of just ablating around each of the PV openings, large, oval lesions are made in the left atrium encircling both the upper and lower vein openings.

PVAI - Ccommon lesion set at A-Fib.com

More extensive lesion pattern

(This is intuitive on my part; we don’t have clinical studies confirming any effect or difference between the two approaches in terms of heart output and atrium function.)

For a runner, the more extensive ablation of the left atrium may affect heart output. Less active patients may not notice the difference, but a runner like you may.

My Best Advice to Runners with Atrial Fibrillation

Seek out the Best EPs: Select the most experienced Electrophysiologists (EPs) you can afford (and travel if you need to). Discuss catheter ablation and your concerns about decreased heart output after ablation. A good EP will make as few lesions during your ablation as possible.

Paroxysmal A-Fib Easiest to Ablate: At the moment you have “paroxysmal A-Fib of recent onset” and it’s usually the easiest to fix. It’s likely you will not need an extensive ablation. (Though one never knows till the actual ablation; Read what Travis Van Slooten wrote about how his “easy case” turned into a complex, extensive ablation.)

Ablate ASAP: Get your ablation as reasonably soon as possible, before your A-Fib has a chance to get worse and requires a more extensive ablation.

Keep your medical records in a binder or folder. at A-Fib.com

Keep A-Fib records in a binder or folder.

Monitor Progress of your A-Fib: A-Fib is a progressive disease. You should track if your heart’s measurements are getting better or worse, and by how much. Ask your doctor for the measurements of heart dimensions and its functions including the diameter and volume of the left atrium, your Ejection Fraction (EF) and any other test results.

Store all your test results and measurements in your A-Fib three-ring binder or file folder.

What Patients’ Need to Know: A progressively enlarging heart and a falling EF percentage (below 35%) means your A-Fib is worsening. To preserve your heart’s best functions, seek an ablation before your A-Fib worsens.

As a runner, even if your heart is somewhat enlarged and your EF has decreased, a successful catheter ablation may not only end your A-Fib and improve your Ejection Fraction but over time may even reduce your enlarged left atrium.

Thanks to Joe O’Flaherty for this question.

If you find any errors on this page, email us. Last updated: Friday, September 9, 2016

Return to FAQ Catheter Ablation and Maze Surgeries

In A-Fib for 15 Years, Eventually is Incapacitated, Unable to Work

Terry Traver' s story at A-Fib.com

Terry Traver’ s story

By Terry Traver, Thousand Oaks, CA, September 2016

I’m a sixty-five year-old male and live in southern California. I am writing this because, as great as Steve’s site [A-Fib.com] is, there aren’t many stories from the west coast.

For over 15 years I suffered with A-Fib. It was not so bad. I stopped using caffeine and chocolate and cut back on my [alcohol] drinking.

Every three months or so I would have an episode that would last about 15 hours and then I would be fine.

Meds never really helped in my case.

A-Fib Progresses to the Point Where I Can’t Work

In 2011, my A-Fib became severe to the point where I was almost completely incapacitated [Persistent Atrial Fibrillation]. I was not even able to work.

Luckily, through a friend I was put in touch with Dr. Anil K. Bhandari, a clinical Electrophysiologist (EP)] at Los Angeles Cardiology Associates in downtown Los Angeles.

Ablation and a Touch-up at Good Samaritan Hospital in Los Angeles

In March 2012, I went in to Good Samaritan Hospital for a catheter ablation (wonderful Hospital and staff). I knew I was a difficult case, so I was not surprised when I had to return in July 2012 for a second touch up ablation (I think Dr. Bhandari was more disappointed than I was).

I knew I was a difficult case, so I was not surprised when I had to return in July 2012 for a second touch up ablation.

Afterwards, no sign of A-Fib. I felt great! At my 30 day return visit and I was told to use up the remainder of my meds and then discontinue them.

A-Fib Free for Five Years

I’ve been A-Fib free for five years. I still doesn’t drink coffee but enjoy chocolate and an occasional cocktail without worry.

Dr. Bhandari and the ablation was the best thing I could have done. I would like to add that the procedure is very easy. I was home the next day. I had no pain and had a short recovery time.

I have nothing but great things to say about my experience with Dr. Bhandari, his staff and Good Sam. Hospital, I live 40 miles north of L.A. and the drive was worth it.

Lessons Learned

Lessons Learned graphic with hands 400 pix sq at 300 resWhat I wish I knew then or did differently:

• I would have had the ablation much sooner. No G.P. [family doctor] ever mentioned ablation as an option. I only heard about it from a friend!
• I had never heard of an electrophysiologist (EP), and wish I had seen one sooner.
• I would learn more about what my insurance covered and what expenses I could negotiate.

I also want to thank Steve Ryan for this wonderful web site. Good luck

P.S. For the guys: For bladder control during the catheter ablation, instead of a urinary catheter, Dr. Bhandari uses a condom. No insertion. Just sayin’.

Terry Traver
terrytraver@gmail.com

Editorial comments:
I’m still amazed when an A-Fib patient tells me his family doctor didn’t refer them to a cardiologist, and more importantly, to an Electrophysiologist.
Atrial Fibrillation is a problem with the electrical function of your heart. Most cardiologists deal with the pumping functions of the heart (think ‘plumber’). It’s important for A-Fib patients to see a cardiac Electrophysiologist (EP)—a cardiologist who specializes in the electrical activity of the heart (think electrician) and in the diagnosis and treatment of heart rhythm disorders.
Terry writes that his GP did not refer him to an EP. Thank goodness a friend stepped in to help him.
It’s so important for patients to educate themselves to receive the best treatment. To learn how to find the right doctor, go to our page: Finding the Right Doctor for You and Your Treatment Goals.
The longer you wait, the worse A-Fib tends to get. Look at Terry’s story. His disease progressed to Persistent Atrial Fibrillation and was incapacitating.

A-Fib is a Progressive Disease—Seek your Cure ASAP!

Note: Dr. Bhandari is still with Los Angeles Cardiology Associates (213-977-0419), also now works at Cedars Sinai in Los Angeles.

Top 10 List #1 Find the best EP your can afford - A-Fib.com

EPs Using Contact Force Sensing Catheters 

Steves Lists of Doctors by Specialty at A-Fib.comTo date I have been unsuccessful in finding or creating a list of Electrophysiologists (EP) usaing Contact Force Sensing Catheters. Two companies make the Contact Force sensing catheters currently on the market:

• Biosense Webster’s Thermocool Smart Touch irrigated tip ablation catheter with force sensing technology, 800-729-9010, 909-839-8500.
• St. Jude Medical’s TactiCath (Endosense) contact-force sensing ablation catheter, 800-328-9634, 651-756-2000

Neither company could provide me with a list of EPs or ablation centers using their contact force sensing catheters. One said that legally they couldn’t hand out such a list due to confidentiality agreements.

I will continue looking for this information and update this page when appropriate.

FAQs Understanding A-Fib: Which Procedure Has the Best Cure Rates

 FAQs Understanding A-Fib: Best Cure Rate

FAQs Understanding Your A-Fib A-Fib.com15. “I have paroxysmal A-Fib and would like to know your opinion on which procedure has the best cure rate.”

The best cure rate isn’t the only criteria you should consider when seeking your Atrial Fibrillation cure.

Let me first review your top three procedure options: cardioversion, catheter ablation, and surgical Maze/Mini-Maze.

Electrocardioversion: When first diagnosed with Atrial Fibrillation, doctors often recommend an Electrocardioversion to get you back into normal sinus rhythm. But for most patients, their A-Fib returns within a week to a month. (However, you might be lucky like the A-Fib patient who wrote us that he was A-Fib free for 7 years after a successful cardioversion.)

Catheter Ablations: Radio-frequency and CryoBalloon catheter ablations have similar success rates 70%-85% for the first ablation, around 90% is you need a second ablation. Currently, CryoBalloon ablation has a slightly better cure rate with the least recurrence.

It’s crucial you choose the right electrophysiologist (EP), one with a high success rate and the best you can afford.

How to achieve these high success rates? It’s crucial you choose the right electrophysiologist (EP), one with a high success rate and the best you can afford (considering cost and any travel expense). What counts is the EP’s skill and experience.

You want an EP who not only ablates your pulmonary veins, but will also look for, map and ablate non-pulmonary vein (PV) triggers. That may require advanced techniques like withdrawing the CryoBalloon catheter and replacing it with an RF catheter to ablate the non-PV triggers. (See our Choosing the Right Doctor: 7 Questions You’ve Got to Ask [And What the Answers Mean].) 

Cox Maze and Mini-Maze surgeries: Success rates are similar to catheter ablation, 75%–90%. But surgery isn’t recommended as a first choice or option by current A-Fib treatment guidelines. Compared to catheter ablations, the maze surgeries are more invasive, traumatic, risky and with longer (in hospital) recovery times

When should you consider the Maze/Mini-Maze? The primary reasons to consider a Maze surgery is because you can’t have a catheter ablation (ex: can’t take blood thinners), you’ve had several failed ablations, or if you are morbidly obese.

Atrial Fibrillation is not a one-size fits all type of disease.

You should also consider that Mini-Maze surgeries have built in limitations. For example, unlike catheter ablations, mini-maze surgery can’t reach the right atrium, or other areas of the heart where A-Fib signals may originate (non-PV locations). The more extensive surgeries create a great deal of lesions burns on the heart which may impact heart function.

So How Do You Choose the Best Treatment For You?

Atrial Fibrillation is not a one-size fits all type of disease.

Your first step is to see a heart rhythm specialist, a cardiac electrophysiologist (EP), who specializes in the electrical function of the heart.

An EP will work with you to consider the best treatment options for you. If your best treatment option is surgical, your EP will refer you to a surgeon and continue to manage your care after your surgery.

To help you find the right EP for you, see Finding the Right Doctor for You and Your A-Fib.

Comment

If you find any errors on this page, email us. Last updated: Wednesday, August 24, 2016

Go back to FAQ Understanding A-Fib

New Story: Cardiologists Offer Little A-Fib Advice to Fellow Doctor

John Bennett, MD, practices emergency medicine in Miami, Florida. Dr. Bennett is known for his series of Google Hangouts live videos featuring experts in a variety of medical fields. To learn more, visit his website, Internetmedicine.com, “Where the Internet Meet Medicine.” His Atrial Fibrillation started at age 57.

John Bennett MD personal A-Fib story at A-Fib.com

John Bennett MD

“As a physician, I had the usual knowledge most physicians have about A Fib—which is not much. Especially the care of chronic Atrial Fibrillation. Like most people, I trusted my cardiologist to do the best thing for me.

First Cardiologist No Options But Drugs—I Hated Coumadin

My first cardiologist did the usual workup, and prescribed Coumadin. I hated that medicine. Made me feel tired, no energy, but I accepted it.

Finally, I got tired of being tired, so I started to do some online research.

I found out that you could elect to be cardioverted, which my first cardiologist did not even mention (since, of course, he would lose me as a patient, if I returned to normal sinus rhythm).

Electrocardioversion Works for 7 Years

I then went straight to an Electrophysiologist (EP), who converted me, and it lasted 7 years. Then last year…” Continue reading Dr. John Bennett’s story->

Stubborn A-Fib Returns Again and From Unusual Areas

We first posted Marilyn Shook’s personal A-Fib story, “Pill-In-the-Pocket” for Five Years, then Catheter Ablation for a Cure (#25) in 2008. She then sent us updates in 2014, 2015 and now her latest update after a third ablation in late April 2016. Marilyn’s A-Fib appears to find new and unusual places to originate from.

Marilyn Shook - A-Fib story at A-Fib.com

Marilyn S.

In her lasted installment, Marilyn writes:

“It’s been a few weeks since my third PVA [Pulmonary Vein Ablation] and I am doing  well.

Just to jolt your memory―I had my first PVA in 2007 and did well for 7 years. But my A-Fib returned in 2014 and was documented by a tiny Medtronic Reveal LINQ cardiac monitor implant. A second PVA followed in October of 2014.

I was A-Fib free until February 2016 when A-Fib/Flutter returned. I opted for my third PVA, which was performed in April 2016 by Dr. David Haines at Beaumont Hospital.

Marilyn Shook is also an A-Fib Support Volunteer who lives near Detroit, MI.

My Third Ablation and Post-Ablation Complication

Under general anesthesia, my PVA was extensive work but completed in about 4 hours. I was in sinus rhythm before and after the procedure. After my ablation, I was awake, alert and responsive and then suddenly became unresponsive, with thready pulse, blood pressure plummeted.

I was having a post PVA complication―a cardiac tamponade―an emergency situation!…”

Continue reading about Marilyn’s third ablation and her medical emergency->.

Cardiologists Offer Little A-Fib Advice, Even to a Fellow Doctor!

John Bennett MD personal A-Fib story at A-Fib.com

John Bennett MD

By John Bennett, MD, July 2016

John Bennett, MD, practices emergency medicine in Miami, Florida. Dr. Bennett is known for his series of Google Hangouts live videos featuring experts in a variety of medical fields. To learn more, visit his website, Internetmedicine.com, “Where the Internet Meet Medicine.”

I had the good fortune to run into Steve Ryan, find his website, and get his book. Ultimately I got fine care and returned to having a healthy heart. My story being at age 57 when I suddenly went into Atrial Fibrillation.

I Trusted My Cardiologist

As a physician, I had the usual knowledge most physicians have about A Fib—which is not much, especially the care of chronic Atrial Fibrillation. Like most people, I trusted my cardiologist to do the best thing for me.

My first cardiologist did not even mention cardioversion to get me back in sinus rhythm.

First Cardiologist No Options But Drugs—I Hated Coumadin

My first cardiologist did the usual workup, and prescribed Coumadin. I hated that medicine. Made me feel tired, no energy, but I accepted it.

Finally, I got tired of being tired, so I started to do some online research.

I found out that you could elect to be cardioverted, which my first cardiologist did not even mention (since, of course, he would lose me as a patient, if I returned to normal sinus rhythm).

Electrocardioversion Works for 7 Years

Well, he did. I then went straight to an Electrophysiologist (EP), who converted me, and it lasted 7 years. I was cardioverted again but this time it only lasted 5 months.

Still, no talk of catheter ablation. I had to chase my doctor down the hall to say, “What’s the plan?”

Research and reading  ‘Beat Your A-Fib’, I found I might be a candidate for catheter ablation.

Ablation and A-Fib Free—“Beat Your A-Fib” Book

Next, I went back to the internet where I ran across Steve’s book, ‘Beat Your A-Fib’ and found I might be a candidate for catheter ablation.

July 2015 I had an ablation by Dr. Todd Florin at Mount Sinai Medical Center in Miami Beach (highly recommended, good listener, super team) and returned to normal sinus rhythm.  It’s been one year and I am still in normal sinus rhythm. If you’ve had A-Fib, I don’t have to tell you the difference between A-Fib and sinus rhythm.

I am truly appreciative about Steve’s work [A-Fib.com] and his book. I feel like a real human being again, with normal energy levels.

Lessons Learned

Lessons Learned graphic at A-Fib.com

Take an active role in your care.

Like Steve says, catheter ablation may not be the answer for every patient with A Fib.

But you need to be aware of it! Read. Be aggressive with your cardiologist. Ask about catheter ablation [and other options]. Take an active role in the care of your pump!

Steve’s book, “Beat Your A-Fib,” motivated me to get active and investigate my treatment options.

Isn’t it sad that TWO of my Cardiologists did not care enough to even mention ablation to me? And I am a friggin’ doctor―and they treated me that way!

John Bennet, MD
Miami, Florida

Editor’s comments
Electrocardioversion best for recent-onset A-Fib: Dr. Bennett was very fortunate to have a cardioversion keep him in sinus rhythm for seven years.
Unfortunately for most patients, a cardioversion seldom lasts that long. It works best in cases of recent onset A-Fib. It’s a very safe procedure and is certainly worth a try, but cardioversion is seldom a permanent cure for A-Fib. Don’t be surprised if you’re back in A-Fib within a week to a month.

Amazing! Dr. Bennett’s fellow physicians didn’t tell him about options like electrocardioversion and catheter ablation.

You can’t always trust cardiologists (or the media): What’s most amazing about Dr. Bennett’s story is that his fellow physicians and colleagues (whom he trusted) didn’t tell him about options like Electrocardioversion and catheter ablation.
Today’s media and web sites talk about “Living with A-Fib”.  But living in A-Fib is detrimental to your long-term health.
In contrast, the message at A-Fib.com is: You don’t have to live in A-Fib. Seek your Cure.

Top 10 List #10 Be your own best patient advocate 600 x 530 pix at 300 res

 

2016 Cost of Ablation by Bordeaux Group (It’s Less Than You Might Think)

David Neth wrote us he’s feeling fine after his recent A-Fib catheter ablation for persistent A-Fib by the French Bordeaux Group [Drs. Michel Haïssaguerre, Pierre Jais and and Meleze Hocini at the Hôpital Cardiologique du Haut Lévêque-(CHU) de Bordeaux]. The Bordeaux Group has the most international experience in ablating persistent A-Fib and uses the ECGI/ECVUE mapping and ablation system. For example, they do 2 persistent A-Fib ablations per day.

David Neth Hopitaux de Bordeaux sign

David Neth at Hopitaux de Bordeaux

We had just updated our article on the Bordeaux Group, and I was curious how the cost compared to an ablation in the US. Here’s what David shared:

Total hospital payment for his 5-day stay was €16,598 (US exchange rate=$ 19,251)

Payment covered: the procedure, operating room charges, all medication and testing, doctors and hospital charges and a private room (including a second bed and 2 extra meals per day for spouse). There were no other charges.

Of course, David had to pay for personal transportation and local living costs.

Putting the Costs in Perspective

In recent years, David had two unsuccessful ablations for his Atrial Fibrillation at the University of Washington Hospital that each cost close to $75,000. His healthcare insurance negotiated the rate down to $48,000 (of which he had to pay $3,500 each time – his annual deductible).

Before booking his procedure in Bordeaux, his Medicare Advantage Supplemental insurance company incorrectly assured him his coverage included “out of country” medical treatment. Sadly, it turned out that this only applied for “emergency services” and their call center had misinformed him.

David shared his thoughts about his out-of-pocket costs:

“I don’t have a large savings and this [Bordeaux ablation] depleted much of it (since I also paid airfare and several nights hotel costs for 3 of us), but I’d have zero hesitancy to do it again if it were necessary. 

At $19,251 US, I feel that’s a small price to pay for cutting edge, successful service!”

David Neth being prepped with Cardio Insight vest with 252 leads; Inset: Front of Cardio vest

[Note: In contrast, my ablation in Bordeaux was covered by my health insurance the same as if the procedure had been in the US.]

To contact the Bordeaux Group, read my updated article on the Bordeaux Group.

The Bordeaux Group: Best in the World for A-Fib Patients!

Think of it—$20,000 for treatment by the best EPs in the world.

Dr. Michel Häissaguerre and his colleagues invented catheter ablation for A-Fib (Pulmonary Vein Isolation). Today their cutting edge research includes using CardioInsight’s noninvasive Electrocardiographic Imaging (ECGI) to map and ablate persistent A-Fib. (ECGI, available only in Europe at this time, will probably revolutionize how ablations are mapped and performed.) Currently at Bordeaux, ECGI is not used for cases of paroxysmal (occasional) A-Fib.

FYI: Drs. Michel Haïssaguerre and Pierre Jais cured my A-Fib in 1998. I was their first U.S. patient. Click to read my story.

My Stubborn A-Fib Returns: A Third Ablation with Post-PVA Complication

A-Fib Patient Story #86

My Stubborn A-Fib Returns: A Third Ablation with Post-PVA Complication

Marilyn Shook - A-Fib story at A-Fib.com

Marilyn S.

By Marilyn Shook, July 2016

Note: We first posted Marilyn Shook’s personal A-Fib story, Pill-In-the-Pocket” for Five Years, then Catheter Ablation for a Cure (#25) in 2008. She then sent us updates in 2014, 2015 and earlier in 2016. Her latest installment is about a third ablation in late April 2016.

It’s been a few weeks since my third PVA [Pulmonary Vein Ablation] and I am doing well.

Just to jolt your memory―I had my first PVA in 2007 and did well for 7 years. My A-Fib returned in 2014. To document any arrhythmia, I had a tiny Medtronic Reveal LINQ cardiac monitor implanted. The captured data confirmed my A-Fib, and I had a second PVA in October of 2014.

Marilyn Shook is also one of our many A-Fib Support Volunteers and lives near Detroit, MI.

I was A-Fib free until February 2016 when A-Fib/Flutter returned. I opted for my third PVA, which was performed in April 2016 by Dr. David Haines at Beaumont Hospital [Michigan].

Post-Ablation Complication: Cardiac Tamponade

Under general anesthesia, my PVA was extensive work but completed in about 4 hours. I was in sinus rhythm before and after the procedure. After my ablation, I was awake, alert and responsive and then suddenly became unresponsive, with thready pulse, blood pressure plummeted.

A Cardiac Tamponade is when blood fills the sac around the heart. During a PVA, it’s usually caused by a small hole created by a penetrating ablation burn.

I was having a post PVA complication―a cardiac tamponade―an emergency situation!

A drain was inserted into my pericardium, [the sac around the heart] and one liter of blood removed. I was transfused with 2 units of blood, then transferred to the ICU with the drain in place. Total blood drainage was about 2 liters.

All I remember is seeing Dr. Haines’ face and hearing all sorts of commands. I remember no pain.

Sent Home but Develops Sinus Tachycardia

After 3 days, the tamponade was under control, and I was discharged from the ICU and sent home. A couple of days later, I felt a very rapid, regular heartbeat. It started on a Sunday, and I waited until early Monday morning to contact my cardiologist.

After a couple of days at home, I felt a very rapid, regular heartbeat. My ECG showed I was in sinus tachycardia, a rapid, but regular heartbeat.”

My ECG showed I was in sinus tachycardia [a rapid, but regular heartbeat], and I was sent to the hospital electrophysiology lab. After a TEE (Transesophageal Echocardiogram) and cardioversion as an outpatient, I converted into NSR [Normal Sinus Rhythm].

Back at home, I did better every day, but initially I was so fatigued. Ten years ago, recovery from my first PVA was rapid and easy. Recovery from my second PVA took a little more out of me, but the recovery was easy.  This time, I was much more fatigued, no pain, just fatigue.  Of course, I am 10 years older than when I had my first PVA, and this time there was a major complication.

My Latest Cardo Appointment: No Arrhythmias!

I saw Dr. Haines in late June and he checked the data from my LINQ monitor―I had no arrhythmias. I am not on any cardiac medications. But I remain on Xarelto for another 6 weeks.

He told me extensive work was performed during my PVA. Interesting was the fact that the pulmonary veins were mapped and all was quiet in that area [from previous ablations]. Much work was performed in the left atrium. There was extensive mapping, remapping, re-ablation, observation and provocative testing.

Lessons Learned

Lessons Learned graphic with hands 400 pix sq at 300 res

The O.R. report from my third PVA documents that my A-Fib was not caused by my pulmonary veins but by non-pulmonary vein triggers.  These triggers were identified and isolated.

Research at this time suggests that there are no significant differences in complication rates between first, second, third or fourth ablations.

We must remember that all ablation procedures have a chance of complications. Cardiac tamponade complications occur in less than 1% of catheters ablations. Never did I think it would happen to me.

To learn how choose the right doctor for you and your treatment goals, see Finding the Right Doctor for You.

I survived and I am doing well because I was at a great hospital with a team of physicians and nursing staff ready to identify and correlate my care during a cardiac emergency.  I had a very knowledgeable electrophysiologist, an expert in the field of Pulmonary Vein Ablations, and top-notch anesthesiology at my side.

All these variables matter, so choose your doctor carefully.

Would I have another catheter ablation?  Yes, if I am a candidate, I would.  But, I have confidence that my A-Fib will not return.

Marilyn Shook
E-mail: nmshook(at)sbcglobat.net

Editor’s Comments

Why Did the Tamponade Happen? Of the nearly 100 Personal Experiences we have published on A-Fib.com, Marilyn’s is the first description of a tamponade. Dr. Haines had to perform extensive mapping, ablation and re-ablation in the left atrium. Somehow one of these catheter ablation burns made a small hole in the heart causing blood to drain from the heart into the pericardium sac.
It’s probable she was at increased risk of a tamponade because of the high difficulty level of her ablation which required more extensive burns than an ordinary ablation. Even the most skilled, experienced EPs can have a tamponade occur.
No Lasting Damage from Tamponade: All experienced EPs and their staffs anticipate and prepare for complications. Dr. Haines and his staff were well prepared and handled this tamponade by draining the leaked blood from the pericardium sac while the small hole in the heart healed by itself. Marilyn went home in three days and was fine. There was no lasting damage to her heart.
This is not to discount the dangers of a tamponade. Without attentive care, Marilyn could have suffered severe heart damage and even have died.
Free download: How and Why to Read Your OR Report – a special 12-page report for Atrial Fibrillation patients by Steve S. Ryan PhD.
For You Technical Types: Marilyn’s O.R. Report: Marilyn sent me her O.R. report so I was able to read what Dr. Haines found and what he did.
He found that Marilyn’s Pulmonary Veins (PV) were still completely silent with no A-Fib. He made a linear ablation line in the left ridge (between the two Left Pulmonary Veins) which terminated her A-Flutter into normal sinus rhythm (that’s the best outcome).
But instead of stopping there, Dr. Haines used electrical signals (pacing) and was again able to induce A-Flutter. He discovered mitral annular flutter and made a linear mitral annular ablation line which again terminated the A-Flutter into sinus.
When he paced again, he found high frequency A-Fib signals coming from the Left Atrial Appendage (LAA). He ablated in this region and extended a linear ablation line towards the base of the LAA which terminated her A-Fib. At this point he ended her ablation.
The locations of Marilyn’s A-Fib/Flutter signals are somewhat unusual. It’s troubling that we don’t know why she developed them. What’s encouraging is that a good, experienced EP was still able to make her A-Fib free.
The Bottom Line: The risk of a tamponade shouldn’t scare you away from having a catheter ablation. Look at how efficiently Dr. Haines and his staff handled Marilyn’s tamponade!
Even in this worst case scenario, Marilyn is fine and A-Fib free.
Find the Best EP you Can Afford: Marilyn did her homework when she selected Dr. David Haines as her EP. She was confident in his treatment advice. She continued to rely on him and his staff over the years as her A-Fib poked up its head again in 2014 and 2016.
This is why we always advise you to see a heart rhythm specialist and to carefully choose your electrophysiologist (EP). To learn how, see Finding the Right Doctor for You.

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If you find any errors on this page, email us. Y Last updated: Saturday, July 23, 2016

Updated FAQ about ‘The Bordeaux Group’ & Dr. Häissaguerre

We’ve updated the contact information in the FAQ asking about Dr. Michel Häissaguerre and the University Hospital of Bordeaux (Hôpital Cardiologique du Haut Lévêque-de Bordeaux) often referred to as ‘The Bordeaux Group’.

“I’ve heard good things about the French Bordeaux group. Didn’t Prof. Michel Häissaguerre invent catheter ablation for A-Fib? Where can I get more info about them? How much does it cost to go there?”

Prof. Häissaguerre and his colleagues invented catheter ablation for A-Fib (Pulmonary Vein Isolation) in the late 1990s. (They cured my A-Fib back in 1998. I was their first U.S. patient. Read my story.) The Cardiologic Hospital of Haut-Lévêque is still considered one of the top A-Fib centers in the world.

How to Contact The Bordeaux Group

Online links to the University Hospital of Bordeaux, Cardiology and Electrophysiology services (Hôpital Cardiologique du Haut Lévêque-de Bordeaux):

• Cardiology and Electrophysiology and Pacing ServicesHead of department: Pr Jean-Michel Haïssaguerre
• Electrophysiology and Ablation, Head of Unit: Prof. Pierre Jais
• Patient Care: Services and Appointment Request – online form

Continue… to read my full answer.

Note: While the website is written in French, my search engine/browser (Google/Google Chrome) offered to translate to English and did a great job! (Learn more at: https://translate.google.com)

FAQs A-Fib Ablations: The Bordeaux Group

FAQs A-Fib Ablations: The Bordeaux Group 

CHU Hopitaux de Bordeaux logo

“The French Bordeaux Group”

26. “I’ve heard good things about the French Bordeaux group. Didn’t Prof. Michel Häissaguerre invent catheter ablation for A-Fib? Where can I get more info about them? How much does it cost to go there?”

Prof. Häissaguerre and his colleagues invented catheter ablation for A-Fib (Pulmonary Vein Isolation). The Bordeaux group at the Cardiologic Hospital of Haut-Lévêque is still considered one of the top A-Fib centers in the world. (They cured my A-Fib back in 1998. I was their first U.S. patient. Read my story.)

In particular, they are doing cutting edge research using ECGI (CardioInsight) to map and ablate persistent A-Fib. ECGI will probably revolutionize how ablations are mapped and performed.

For the 2016 costs, see my post about David Neth.

How to Contact the Hôpital Cardiologique du Haut Lévêque-(CHU) de Bordeaux 

Online links to University Hospital of Bordeaux, Cardiology and Electrophysiology services (June 2016):

Cardiology and Electrophysiology and Pacing ServicesHead of department: Pr Jean-Michel Haïssaguerre
• Electrophysiology and Ablation, Head of Unit: Prof. Pierre Jais
• Patient Care: Services and Appointment Request – online form (in English)

2010 Article by The Bordeaux Group

Here is something they published in 2010 which explains their methodology and the costs of being treated at Bordeaux. Published as: Are you a good candidate? http://Are you a good candidate?

CATHETER ABLATION OF ATRIAL FIBRILLATION

Currently the only treatments that cure atrial fibrillation (AF) are:

a) Surgery (such as the Cox Maze operation and its variations)
b) Catheter Ablation

The main goals of catheter ablation of AF are to:

1) restore the heart to normal sinus rhythm, thereby eliminating the symptoms of AF.
2) relieve the patient from the associated risks of AF, such as blood clot formation, stroke, cardiac failure, and increased mortality. (It has not been proven that a successful Catheter Ablation will achieve these goals in all A-Fib patients.)

In the catheter ablation procedure a catheter, a soft, thin, flexible tube with an electrode at the tip, is inserted through a large vein in the groin and moved into the heart. This catheter delivers Radiofrequency (RF) energy to cauterize and eliminate the sources or spots in the heart (ectopic foci or wavelet circuits) that are triggering or maintaining the episodes of AF. These sources or spots in the heart are usually found in the pulmonary vein openings. The catheter also makes linear lines or lesions to segment the atrial tissue, thereby interrupting the errant electrical waves responsible for maintaining AF.

This isolation of the pulmonary veins cures the intermittent (paroxysmal) form of AF in 80% of patients (without having to take any medications). An additional 10% of patients are improved—an antiarrhythmic drug keeps them is sinus rhythm without the need for blood thinners.

For patients with permanent or persistent AF (lasting more than 48 hours or who have had Electrocardioversion), isolation of the pulmonary veins is less effective and should be combined with linear lines or lesions. This is because the longer one has episodes of AF, the more the sources or spots in the heart which produce AF signals tend to spread outside the pulmonary veins.

Ablated heart tissue has a tendency to heal itself and recover. For this reason and to increase the success rate to 90%, more than one procedure is required after 1-3 months of follow-up.

PRE-ABLATION MANAGEMENT

For safety reasons (to avoid clot formation during the catheter ablation procedure) the patient should take oral anticoagulation (coumadin, not aspirin) at an optimal therapeutic range (INR 2-3) for at least 1-2 months before the procedure. In addition, a transesophageal echocardiogram should be performed a few days before hospitalization to make sure there are no clots in the heart, particularly in the left atrial appendage. If clots are found, the procedure must be postponed a few days until these clots can be dissolved by blood thinners.

Anticoagulants should be interrupted 48 hours before the day of the procedure. If the patient is taking antiarrhythmic drugs, they should be stopped on admission.

CATHETER APPROACHES

General anesthesia is rarely performed on adult patients, in order to minimize the associated risks of anesthetic drugs. The patient is slightly sedated and a local anesthetic is applied to the groin area. Usually three catheters for mapping and ablation are inserted through one or two femoral veins in the groin and moved up into the heart.

The mapping catheters have multiple electrodes mounted in a longitudinal or circumferential shaft. (Other configurations including investigational designs may be used for individual situations.) The ablation catheter has an irrigated tip to prevent local clot formation and to allow greater energy delivery if needed (at thick parts of the cardiac tissue). To insert these catheters into the left atrium, it is usually required to make a puncture of the transseptal wall between the two upper chambers (atria) at what is called the foramen ovale. After the ablation procedure, this foramen ovale closes back up and heals over. (In 20% of patients this foramen ovale hole never closes up completely and remains open, creating a pathway between the two atria chambers.)

Two or three physicians usually perform the catheter ablation procedure. They are involved in positioning the catheter, and in the collection, analysis and interpretation of heart signals obtained during conventional or computerized mapping.

RF ablation is performed around the openings of the pulmonary veins, one by one or two by two, using a limited level of energy to avoid swelling of the pulmonary vein openings or atrial perforation. Isolation of the pulmonary vein openings is successfully performed in 100% of cases.

In paroxysmal (occasional) AF, PV isolation cures AF in 60-70% of cases. Ablation of the appropriate site in the right atrium (Cavotricuspid Isthmus) is also performed to prevent right atrial flutter. Linear block here is successfully achieved in 99% of cases.

In persistent AF (lasting more than 48 hours or with a history of electrical cardioversion), PV isolation is rarely sufficient. Additional RF applications are required to eliminate spots of AF activity outside the pulmonary veins. In the most resistant cases (usually long lasting AF), linear ablation similar to surgical incision is performed in the left atrium between the two superior PV and/or from the vein to the mitral annulus (mitral “isthmus”). This achieves linear block in 90% of cases. The success depends on achieving continuous and coalescent cauterizing lesions to create a complete barrier. Any gap in the lesion line, even of a millimeter size, allows AF signals to cross thereby keeping the heart in AF. A gap in the lesion line is due either to a too thick atrial wall or recovery of atrial tissue during the 1-4 week healing process following ablation.

Pain and discomfort associated with ablation are controlled by Midazolam and Morphine. Because there are no nerve endings in the smooth tissue of the heart and veins, the pain and discomfort are minimal and usually well tolerated.

DURATION OF OPERATION AND HOSPITAL STAY

The duration of the procedure varies from one to five hours depending on individual conditions:

• the number of ectopic sources in the atrial tissue (outside the pulmonary veins) may require more mapping time.
• successful lineal ablation lines depend on the thickness of the heart wall which varies from one patient to another and can not be precisely determined by pre-ablation imaging.

The end point or goal of the procedure is the achievement of local block in all targeted structures (veins and isthmuses) so that no AF signals travel through the heart. In addition, after the ablation multiple pacing maneuvers are used to try to induce sustained AF. In paroxysmal AF, multiple pacing maneuvers do not induce AF in 90% of cases.

A second procedure may be needed within 3-5 days in 25% of AF patients due to partial recovery of ablated tissue and/or secondary AF sources not ablated in the original procedure. In difficult cases of multiple or unmapable ectopic foci (heart tissue generating AF signals), a second linear ablation may be required in the left atrium.

Patients are hospitalized 4 to 6 days depending on the number of procedures required. Typically they return to the normal care

unit after ablation and are ambulatory 12 to 24 hours later. They are monitored by telemetry during the next 3 days when any recurrence of arrhythmia is most likely to occur. The likelihood of recurrence decreases over the next month.

Patients are usually admitted on Monday and can leave the hospital for the week-end, if there are no complications. They must stay in the region during the week-end and must return the following Monday for outpatient evaluation, which could result in re-hospitalization if needed.

The occurrence of complications may increase the duration of the hospitalization and therefore the cost. In our experience, this happens to 2.5% of patients.

If AF symptoms do not reoccur, patients can return home and resume normal activities. Anticoagulants are recommended for at least 1-3 months after ablation, and can then be stopped if there is no AF or other risk factors. In persistent AF, antiarrhythmic medications are recommended for 1-3 months after ablation to enable the atria to return to normal (this process is called “remodeling.”)

POPULATION OF PATIENTS

Catheter ablation of AF has been performed since 1994 in Bordeaux. As of October 2009, over 6,000 patients have been treated. At least 15 cases of atrial fibrillation or flutter are treated every week. The clinical characteristics of patients cover a wide spectrum of age (15-84 years old, average 52 years old). 78% of patients are male, while 22% are female. 80% have paroxysmal (occasional) AF, 20% have persistent AF. All patients were resistant to or intolerant of an average of 4 antiarrhythmic drugs and experienced at least weekly episodes of AF at their referral.

Some patients had documented pauses in their sinus heart beat after an attack of AF. They were cured by AF ablation, and thus avoided pacemaker implantation. 12% reported a previous embolic event (stroke), most in the circulation of the brain.

In patients with heart failure and permanent AF, the restoration of sinus rhythm (normal heart beat) is associated with a significant improvement of ventricular function in 80% of the patients.

RISKS ASSOCIATED WITH AF CATHETER ABLATION

Currently no one has died of a catheter ablation procedure in our department. Compared to other catheter procedures a 0.1% risk of death is a reasonable estimation.

The other risks of catheter ablation of AF are:

• bleeding in the pericardial sac surrounding the heart and requiring drainage (0.5-1%)
• embolic event (stroke) (0.2%)
• groin access hematoma (bruising) (4%)

There is no risk of sinus node or AV node damage by ablation which would require implanting a pacemaker.
World-wide there have been deaths reported by the use of high wattage catheters (50 watts or higher) creating a fistula (burn through) to the esophagus, usually 2 days after the procedure. We have not observed this complication.
Pulmonary vein narrowing (stenosis), if it did occur, would not usually cause symptoms. Out of 6,000 patients treated in our institution, 7 developed symptoms due to PV narrowing (>70% of lumen [opening] diameter) and required angioplasty and stenting.

The above risks compare very favorably with the risks involved in living with untreated AF. The risks of catheter ablation also compare very favorably with the risks involved in taking antiarrhythmic drugs and anticoagulants.

PROCEDURE COSTS (2010)

This cost is fixed by the public health administration.  The cost for a private service (operators: Drs. M. Haissaguerre/P. Jais/ M. Hocini) is 5000 euros (around $6,000) (hospital and physician charges). The total cost of AF catheter ablation depends on the duration of one’s stay in the hospital, which depends on the difficulty of individual ablation cases.

The typical hospital stay of 5 days with an ablation including pulmonary vein isolation and ablation of the right and left atria would cost about 10,328 euros (around $12,600). One day more or less would be 2044 Euros (around $2,500).

The total costs of a 5 day stay and ablation would be 17,600 euros (around $21,500).
For patients accompanied by a family member and without local accommodations, a meal, bed and breakfast is provided in the same room 27,10 euros/day (around $33.00).

The current waiting time for a procedure is 2 months.

Patients should come with personal clothes, since it is possible to walk outside. Patients are generally expected to wear their own clothes, including pajamas. Since the hospital only provides small towels, you may wish to bring your own towels.

INFORMATION ABOUT THE HOSPITAL

Cardiologic Hospital of Haut-Lévêque is a 300 bed hospital entirely dedicated to medical and surgical cardiology. It is located in Pessac and is a 20 minute drive from the airport, and a 20-30 minute drive from the center of Bordeaux and the TGV station.

Languages spoken: English and Spanish

The web site is: http://www.chu-bordeaux.fr/LES-HOPITAUX-ET-SITES-DU-CHU/Groupe-hospitalier-Sud/Hôpital-Haut-Lévêque/.

If you find any errors on this page, email us. Y Last updated: Monday, July 25, 2016

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CryoBalloon Ablation: All EPS Are Not Equal (Part II)

Second in a two-part series by Steve S. Ryan, PhD

In Part I of this article, I shared my dismay at reading two O.R. reports of Cyroballoon Ablations that left me alarmed and disturbed. The first case was performed at one of the most prestigious A-Fib centers in New York City.
In each case, what’s alarming is what the EP didn’t do! The CryoBalloon ablation was less than the standard. The very minimum steps were taken.

Is Performing CryoBalloon Ablations Too Easy?

That relative ease has lead some EPs to cut corners. They just isolate the PVs without doing anything else.
CryoBalloon ablation is relatively easy to perform compared to RF (point-by-point) ablation.

That relative ease has lead some EPs to cut corners. They just isolate the PVs without doing anything else—they don’t bother to identify where A-Fib signals (potentials) are coming from and they don’t try to induce A-Fib after the ablation.

Some EPs performing CryoBalloon ablations may not have a full skill set. Others may lack the motivation to hunt for non-PV triggers.

My fear: If this becomes a trend, I fear CryoBalloon may become a step backwards as a treatment for A-Fib patients. Could CryoBalloon Ablation turn into a second-tier or inherently inferior procedure?

Choosing an EP for a Cryoballoon Ablations

Are you considering a catheter ablation (RF or Cyro)? Before selecting your electrophysiologist (EP), you must do your research and check their credentials and experience. For guidelines, see our Find the Right Doctor for You and Your A-Fib.

When choosing an EP for a Cyroballoon Ablation, you should research:

1. Are they certified in Clinical Cardiac Electrophysiology (CCE)?
2. Did they have a good track record doing RF ablation before they switched to CryoBalloon ablation?
3. Do they perform at least 25 ablations a year to maintain their proficiency?
4. Will this EP commit to pursue and ablate non-PV triggers?

Take Away: All EPS Are Not Equal

You want an EP with a proven track record in RF ablation who can call on those skills if needed to identify and ablate non-PV triggers.

You don’t want an EP new to the field who is only doing CryoBalloon ablations because they are so much easier to do. EPs don’t all have the same training, skill level, and motivation. Indeed, many non-CCE certified EPs perform catheter ablations for A-Fib.

You want an EP with a proven track record in RF ablation who can call on those skills if needed to identify and ablate non-PV triggers. The EP should have established protocols for doing this and should be able to explain them to you. For example, something like this:

“If you are still in A-Fib after Cryoablation of the pulmonary veins, I will withdraw the CryoBalloon catheter and replace it with an RF catheter. I’ll identify the non-PV trigger spots, then isolate each with the RF catheter.”

All EPs are not equal. To become A-Fib-free, do your homework! Find the right EP for your Cyroballoon ablation.

Additional reading: To learn more about O. R. reports see our Special Report: How & Why to Read Your Operating Room Report

CryoBalloon Ablation: Alarming O.R. Reports (Part I)

A two-part series by Steve S. Ryan, PhD

Often when A-Fib patients contact me, I’ll advise getting a copy of their O.R. (Operating Room) report so I can read exactly what was done during their ablation. The details in an O. R. report can be quite revealing and usually reassure me that their EP did a good job.

An O.R. report of a catheter ablation is a blow-by-blow account of your EP’s actions.

But sometimes the report is disappointing. I just read two O.R. reports of CryoBalloon ablations that left me alarmed and disturbed.

O.R. Report #1: Ablation Without Identifying the Source of A-Fib Signals

The first CryoBalloon ablation was performed at one of the most prestigious A-Fib centers in New York City.

At the beginning of the ablation, it appears the Electrophysiologist (EP) made no attempt to first map the source of the patient’s A-Fib signals (mapping at the beginning or before hand is standard procedure at most A-Fib centers).

During the ablation the EP did not check for non-PV triggers or even attempt to identify the source of her A-Fib signals or potentials. The EP merely ablated the pulmonary veins (PVs), but did check for entrance and exit block.

At the beginning of the CryoBalloon ablation, the EP made no attempt to first map the source of the patient’s A-Fib signals.

At the end of the CryoBalloon ablation, he did not verify all A-Fib signals had been terminated by trying to trigger A-Fib with pacing or drugs like isoproterenol. (Triggering A-Fib means a new round of A-Fib isolation.) Once again, this verifying step is standard protocol for most ablations at most centers.

Result: the CryoBalloon ablation appeared to successfully isolate the patient’s PVs, and luckily she seems to be doing well.

My Observations

What’s alarming is what the EP didn’t do! This CryoBalloon ablation was less than the standard.

The very minimum steps were taken: isolate the Pulmonary Veins and little more. There was no effort to check for non-PV sources of A-Fib signals. No verification that all A-Fib sources were terminated. In fact, this patient may still have spots producing A-Fib signals.

Why go through an ablation if the EP didn’t do a thorough job? If the patient’s A-Fib returns, a second ablation may be required.

Now you know why I was disturbed by this O. R. report. Now, let’s look at the second report.

O.R Report #2: Non-PV Triggers Still Causing A-Fib

I read another O.R. report of a CryoBalloon Ablation on a patient who was in persistent A-Fib for two months before the ablation.

After isolating the PVs, the patient remained in A-Fib.

After isolating the PVs, the patient remained in A-Fib…the EP simply electrocardioverted the patient back into normal sinus rhythm.

Instead of looking for and ablating the source of these non-PV triggers, the EP simply electrocardioverted the patient back into normal sinus rhythm. (That’s certainly faster and easier than looking for non-PV triggers.)

Result: The patient was back in A-Fib within a month.

MY OBSERVATIONS

According to the patient, when the patient and his family first met with the CryoBalloon ablationist, they asked the right questions:

“What will you do if I still have A-Fib after the ablation?”

The EP said he would not stop until all the A-Fib spots were found and ablated.

In reality, instead of doing that, he just electrocardioverted the patient back into normal sinus rhythm without looking for and ablating the patient’s still-firing non-PV triggers.

It’s no wonder the patient was back in A-Fib shortly after this ablation.

Again, I was alarmed and troubled by what I read.

Take Away: O. R. Reports

An O.R. report is a blow-by-blow account of your EP’s actions. Indeed, the details in an O. R. report can be quite revealing. In these two cases, alarmingly so.

Read our free report.

Read our free report.

If you’ve had an ablation that was less than successful, you want to know why! Your O.R. report would show what they found in your heart, what was done, and possibly why the ablation didn’t fulfill expectations.

Read more about O. R. reports in our Special Report How & Why to Read Your Operating Room Report

NEXT TIME, IN PART II: Is Performing CryoBalloon Ablations too Easy?

New FAQ: Post-Ablation and Increased Heart Rate

I’ve answered a new question from a patient who’s post-ablation with a higher than previous heart rate:

“I’m six months post CryoBalloon ablation and very pleased. But my resting heart rate remains higher in the low 80s. Why? I’ve been told it’s not a problem. I’m 64 and exercise okay, but I’ve had to drop interval training.”

It’s common after an ablation for one’s heart rate to increase somewhat, but usually returns to normal as the heart heals. That’s probably because the heart’s nerve endings have been irritated by the ablation. Although I’ve heard of some patients whose heart rate remains higher than it was before ablation. This is an area that hasn’t been well investigated.

If your higher heart rate affects you, there are steps you can take to lower it. Continue reading

65 and Older: 99% Have Microbleeds—So Are Anticoagulants Risky?

In a  recent study, 99% of subjects aged 65 or older had evidence of microbleeds; and closer examination of the cranial MRI images revealed an increased number of detectable microbleeds (i.e., the closer they looked, the more microbleeds they found).

Microbleeds in the brain are thought to be a precursor of hemorrhagic stroke.

Cerebral microbleeds (MBs) are small chronic brain hemorrhages of the small vessels of the brain.

If Microbleeds Cause Hemorrhagic Stroke, Should I be on a Blood Thinner?

The fact that almost everyone 65 or older has microbleeds is astonishing and worrisome, particularly if you have A-Fib and have to take anticoagulants. Anticoagulants cause bleeding. That’s how they work.

In plain language, this study indicates that cerebral microbleeds lead to or cause hemorrhagic stroke. It’s not surprising then that some doctors are reluctant to prescribe heavy-duty anticoagulants to older A-Fib patients.

Being older and already having microbleeds only makes taking anticoagulants all the more worrisome.

Risks of Taking Anticoagulants (Blood Thinners)

Taking most any prescription medication has trade-offs. Older A-Fib patients find themselves between a rock and a hard place.

In the case of anticoagulants, on one hand you get protection from having an A-Fib stroke (which often leads to death or severe disability), but on the other hand you have an increased risk of bleeding.

For those over 65 who already have microbleeds, … Continue reading this report…->

FAQs A-Fib Ablations: Increased Heart Rate after Ablation

 FAQs A-Fib Ablations: Elevated Heart Rate 

Catheter Ablation

Catheter Ablation

25. “I’m six months post CryoBalloon ablation and very pleased. But my resting heart rate remains higher in the low 80s. Why? I’ve been told it’s not a problem. I’m 64 and exercise okay, but I’ve had to drop interval training.”

It’s common after an ablation for one’s heart rate to increase somewhat, but it usually returns to normal as the heart heals. That’s probably because the heart’s nerve endings have been irritated by the ablation. Although I’ve heard of some patients whose heart rate remains higher than it was before ablation. This is an area that hasn’t been well investigated.

We may have to list “increased heart rate” as a possible consequence of an ablation. But, as you have already experienced, it sure beats living in A-Fib.

Exercise to Lower Heart Rate: If your higher heart rate affects you, there are steps you can take to lower it. As you are already doing, long-term exercising at a moderate/high level helps lower heart rate. (I am a fairly fit 75-year-old sprinter. My heart rate over the years has dropped down to the 50s.)

Beta Blockers to Lower Heart Rate: Discuss your increased heart rate with your EP and how it affects you. Ask if short-term use of medication such as beta blockers may help you.

Warning: But only take beta blockers (or medications like them) for a short time, certainly not for life.  These type of drugs have bad side effect over the long term. (Bob writes that metoprolol hasn’t lowered his heart rate after ablation.)

Resources Needed: If anyone his run across more research or has insights into this question of higher heart rate after an ablation, please let us know. Thanks to Bob for this question.

If you find any errors on this page, email us. Y Last updated: Wednesday, May 18, 2016

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2016 AF: Four New Reports on Predictors, Protocols, Rotors & 2 Difficult Ablation/LAA Cases

New Reports by Drs. Haissaguerre, Wilber, Reddy & Valderrabano

I’ve been rather prolific with my summaries of key presentations from the recent 2016 AF Symposium (January, Orlando, FL). Four new reports have been posted at 2016 AF Symposium: My Summary Reports Written for A-Fib Patients.

Dr Michele Haissaguerre, The Bordeaux Group

Dr Michele Haissaguerre

You might want to start with two presentations by the A-Fib research pioneer1Dr. Michel Haissaguerre of Central Hospital, Bordeaux, France (he cured my A-Fib in 1998):

Predictors of Unsuccessful Ablations: It’s All About Remodeling
• Bordeaux New ECGI Ablation Protocol—Re-Mapping during Ablation

Then move on to the very HOT topic of Rotors, and two difficult cases of ablation with LAA closure:

• Rotors! Rotors! Rotors! Good News for Patients with Persistent A-Fib. presented by Dr. David Wilber of Loyola University Medical Center, Chicago, IL
• Two Challenging, Difficult Catheter Ablation Cases with LAA Closure by Dr. Vivek Reddy, Mount Sinai Hospital, New York, NY and Dr. Migel Valderrabano, Houston Methodist Hospital, Houston, TX

More Reports to Come

Steve at 21st Annual AF Symposium in Orlando FL

Steve at 2016 AF Symposium

 You can see a list of my first six reports at 2016 AF Symposium: My Summary Reports Written for A-Fib Patients.

For an introduction to the 2016 AF Symposium, don’t miss my brief Overview.

I expect to write 15 – 20 additional reports in the coming months. So visit the reports list often. Just use the left menu tab “2016 AF Symposium Reports” (found on every page) to go to my growing list of reports.

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References    (↵ returns to text)
  1. Pioneer in the Ablation of A-Fib: In 1997, a major breakthrough came to AF ablation as Dr. Michel Haïssaguerre and his researchers observed that a vast majority of A-Fib was initiated by triggers from a focal source in the Pulmonary Veins (PV) and ablation of the focal source in the PV eliminated Parosysmal A-Fib.

2016 AF: Thickening of Left Atrium and Fibrosis Amount Predicts Outcome of A-Fib Ablation

AF Symposium 2016

Thickening of Left Atrium and Amount of Fibrosis Predicts Outcome of A-Fib Ablation

by Steve S. Ryan, PhD

Dr. Nassir F. Marrouche

Dr. Nassir F. Marrouche

Dr. Nassir F. Marrouche, University of Utah (CARMA), is known for ground-breaking, thought-provoking research using MRI. His presentation was entitled “Atrial and Ventricular Myopathy: A Novel risk predictor for stroke and cardiovascular events.”

Amount of Fibrosis Better Predictor of Stroke Risk (and Heart Attack)

Dr. Marrouche began by showing how today’s stroke guidelines (CHADS2 or CHA2DS2-VASc) are mediocre predictive tools overall, according to most studies. Whereas atrial fibrosis detected by Delayed Enhancement-MRI (DE-MRI) is a better predictor of stroke risk.

DE-MRI stands for Delayed Enhancement Magnetic Resonant Imaging.

In Dr. Marrouche’s study, patients with more than 21% fibrosis had a 19.6% risk of stroke while those with under 8.5% fibrosis had only a 1% risk. The more fibrosis, the greater risk of clots forming in the Left Atrial Appendage (LAA).

In a study by King, higher levels of fibrosis were associated with ‘Major Adverse Cardiac Events’ (MACE), not only stroke but heart attack and deep vein thrombosis (a blood clot within a vein).

Cardiomyopathy and Fibrosis

Dr. Marrouche showed slides of normal atrial myocytes (muscle cells) vs. examples with extensive fibrosis where collagen replaced most of the red myocytes (which store oxygen until needed for muscular activity).

This is an important finding which may change the way we look at fibrosis.

This fibrosis correlated with abnormality of the atria (atrial myopathy) and deterioration of the ability of heart muscles to contract (cardiomyopathy). This is an important finding which may change the way we look at fibrosis.

(For further information on Dr. Marrouche’s work, see Higher Fibrosis at Greater Risk of Stroke and Precludes Catheter Ablation.)

Fibrosis/Myopathy Correlates with Atrial Strain

Dr. Marrouche showed slides of how the left atrium of an A-Fib patient with extensive fibrosis worked much harder to pump and had nearly three times more strain than a patient with mild fibrosis. (This may be why the left atrium often stretches and expands in remodeling.)

A-Fib Thickens Left Atrial Shape

In another ground-breaking observation, Dr. Marrouche showed slides of how the shape of the left atrium (LA) gets thicker as one progresses from no-A-Fib to paroxysmal to persistent A-Fib. In fact, in a study by Bieging, LA shape (thickness) is a strong independent predictor of outcome after AF ablation.

Left Atrial Appendage and Stroke Risk

Dr. Marrouche found that the Left Atrial Appendage (LAA) length, thickness and orientation correlate with stroke risk. These findings open up new avenues of research in A-Fib. Just looking at the LAA might produce an indication of stroke risk, which can be combined with other predictive measures.

Left Ventricular Disease Predicts Recurrence after Ablation Therapy

Some A-Fib patients also have a diseased Left Ventricle (LV) which shows up using ‘Late Gadolinium Enhancement- MRI’ (LGE-MRI). In a study by Suksaranjit, the recurrence rate after an ablation was 69% in patients with Left Ventricular LGE-MRI revealed disease, compared to 38% in patients without LV LGE-MRI. These patients also have more major adverse cardiac and cerebrovascular events.

Conclusion

Dr. Marrouche is now using both the amount of fibrosis and left atrial shape to stage and treat A-Fib patients. The main points we can learn from Dr. Marrouche’s research are:

Fibrosis makes the heart stiff, less flexible and weak, overworks the heart, reduces pumping efficiency and leads to other heart problems.

• Fibrosis puts you are greater risk of a stroke and other vascular problems.
• More fibrosis leads to thickened heart tissue, strains the heart and reduces the ability of the heart muscles to contract.
• A-Fib changes the thickness/shape of the left atrium.
• A-Fib can also change the length, thickness and orientation of the Left Atrial Appendage (LAA).
• Left Ventricular disease may accompany or be caused by A-Fib, be measured by MRI, and predict recurrence after catheter ablation..

What Patients Need To Know

Don’t delay! Your A-Fib leads to fibrosis! A-Fib produces fibrosis which is considered permanent and irreversible. Any treatment plan for A-Fib must try to prevent or stop remodeling and fibrosis.

Caveat: After reading Dr. Marrouche’s research and new insights that atrial fibrosis detected by DE-MRI is a better predictor of stroke risk (than CHADS2 or CHA2DS2-VASc), don’t rush into your EPs office asking about using MRI to diagnose your amount of fibrosis. Not every MRI technician and doctor has the special training and experience necessary to perform Dr. Marrouche’s testing. (And insurance companies may not want to pay for this testing. However, that may soon change.)

References for this article

Return to 2016 AF Symposium Reports by Steve Ryan, PhD

If you find any errors on this page, email us. Y Last updated: Monday, February 22, 2016

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